Abstract
A study was conducted of hospital gynecological registers and patient/client files to identify health care interventions that could help reduce abortions and promote reproductive health in Seychelles. While the pregnancy rate in the country has fallen, the proportion of pregnancies ending in unsafe abortion has risen. Almost half the teenagers who had an abortion in 1996/1997 were under 18. Out-of-school unemployed teenagers seem to be particularly at risk of having unsafe abortions. Most women having an abortion in 1997 had less than 2 children. Among the women aged 20 or over with unplanned pregnancies, almost all of them had used contraception in the past but around 70% were not using a method at the time of conception. About half of the teenagers had never used a method and around 86% were not using a method at conception. A quarter of the women who had a therapeutic abortion during the 50-month study period also had sterilization. Recommendations are made concerning record keeping and service provision and the need to focus preventive health care on young unemployed women and their families. (SMDJ, 1999;6;4-10.)
Introduction
Accurate statistics concerning induced abortion are only available from countries where all (or almost all) abortions are carried out legally or where national community based studies have been conducted. In countries where access to legal abortion is restricted or non-existent, figures are obtained from estimates which are usually based on the number of admissions to hospitals for the treatment of complications caused by illegal or self-induced abortion. Recent estimates put the annual number of induced abortions worldwide at between 36 and 53 million: an average of about one abortion per woman in a lifetime, or 4% of all women aged 15 to 44 each year. The lowest known induced abortion rate among women aged 15 to 44 is 0.5% per year (in the Netherlands) and the highest 18.8% per year (Romania, in 1990) (1). Ketting estimates that worldwide, probably one quarter of all pregnancies are deliberately terminated (1).
In Seychelles, no community-based studies have been conducted but the impression from hospital admission figures is that unsafe abortions have increased since the early nineties. The objective of this study was to identify interventions, and target groups for these interventions, that could help reduce abortions (especially repeat ones and complicated ones) and promote reproductive health.
Methods
First, the Victoria Hospital gynecology ward (Hermitte Ward) register of admissions between 1 November 1993 and 30 September 1995 provided the names, addresses, employment, diagnoses and dates of admission and discharge of patients admitted with abortions or threatened abortions during that period. Hermitte Ward is the only hospital ward in the country where abortions are managed. However, some of the information was incomplete or inaccurate, particularly with regard to employment, the spelling of names and the final diagnosis. It was not practical to use the admissions register as a source of information for admissions beyond September 1995 because those admissions had been recorded in the register that was still in continuous use on the ward. When there was more than one admission for the same pregnancy, only the last recorded admission for the pregnancy was maintained.
Second, the discharge forms, filled in on a daily basis by ward nursing staff and submitted to the Statistics Unit on a weekly basis, were used to correct/double check the above data (except that on employment, which is not recorded on the discharge form). These forms were also used to obtain the names, addresses, diagnoses and dates of admission and discharge of patients admitted to the ward between 1 October 1995 and 31 December 1997. It should be noted that the nurses tend to consult the nursing cardex rather than the medical notes when filling in these forms.
Third, the Termination of Pregnancy (TOP) Register was used to correct/double check information on those patients who had a therapeutic termination of pregnancy between 1 November 1993 and 31 December 1997.
Fourth, an attempt was made to retrieve the hospital medical files of all patients who appeared to have been admitted to hospital because of abortions/threatened abortions involving more than one pregnancy during the initial 32 months of the study period: November 1993 to June 1996. Medical notes were also sought for 3 patients whose diagnoses conflicted with other available information. Of the 81 medical files requested, only 31 were found by the nurse who works in gynecology outpatients. Her ability to retrieve the notes was hampered by the fact that the file numbers and dates of birth of the patients were not available because they are not recorded in the admissions register or on the discharge forms. In the 31 files that were found, there was no record of 21 of the admissions. In some cases the missing records were in the maternity notes but the whereabouts of the others remains a mystery. Part of the problem is that the same person may use 2 or more different names. For one patient the records of one admission were in the file of a young girl with the same name and her own file was not found. Sifting through the files for information was a laborious and time-consuming task as the contents were often stored in an untidy and haphazard manner. File numbers for maternity notes were identified for 55 of the 81 patients and about 40 of these files were retrieved. They were in better order than the gynecology notes described above but histories of abortions were sometimes incomplete.
Fifth, a post-abortion counseling service was introduced at the hospital in July 1996 which was able to reach 42% of the women admitted to hospital because of an abortion during the last 18 months of the study period. A register was kept of the women seen, including their name, address, date of birth, medical record number, date and type of abortion, gestation, parity, date of last delivery and relevant remarks about past history, future management and contraceptive choice. Data from this register was added to that obtained from the previously mentioned sources.
Sixth, a list was made of the names, addresses and ages of 136 clients whose FP notes were required for additional information. The list included those who appeared to have had more than one pregnancy resulting in abortion/threatened abortion during the initial 32 months of the study period and those where the diagnosis was not clear. A search at four health centers revealed further information about 16 of the 34 women on the above list who lived in the districts served by those health centers and still the information was often incomplete. It was felt that the time and effort that would be required to search for further information in the other health centers would not be justified by the relatively limited additional information that would be obtained. The information obtained from all the above sources was fed into a Foxpro file with one record for each separate pregnancy.
Results
There are records from Victoria Hospital of 1360 abortions between 1 January 1994 and 31 December 1997.
The information gathered as described above, together with that obtained from the TOP register for 1987 to 1992, service statistics from the Statistics Unit and figures from the Civil Status Office were used to obtain the information in Table 1 and Figure 1.
Abortion rates and ratios
Although the average number of abortions per year increased from 276 in the 1986 to 1990 period to 334 in the 1991 to 1995 period, the number of women in the fertile age range also increased so that the number of abortions per 1000 women remained steady. If we assume that in 1995 at least one third of non-therapeutic abortions were spontaneous (this assumption is based on information gleaned from the medical records) then in that year about 12 per 1000 women aged 15 - 44 had an induced abortion. This figure is comparable with that for Finland and lower than that for England and Wales, Canada, Norway, Sweden, Denmark and Singapore in the eighties (1). It does not take account of those who go overseas for an abortion and do not require admission on their return, or those who have illegally induced abortions in Seychelles but do not present themselves for admission, but it probably underestimates the proportion of abortions that are spontaneous.
| Table 1. Abortions in Hermitte Ward, 1987 to 1997 | ||||||
| Year |
|
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|
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|
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| 1987 |
|
|
|
|
|
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| 1988 |
|
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|
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| 1989 |
|
|
|
|
|
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| 1990 |
|
|
|
|
|
|
| 1991 |
|
|
|
|
|
|
| 1992 |
|
|
|
|
|
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| 1993 |
|
|
|
|
|
|
| 1994 |
|
|
|
|
|
|
| 1995 |
|
|
|
|
|
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| 1996 |
|
|
|
|
|
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| 1997 |
|
|
|
|
|
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| Total |
|
|
|
|
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|
From 1986 to 1990, there was an average of 124 recorded pregnancies for every 1000 women aged 15 to 49 per year. This figure dropped to 109 for 1991 to 1995 and to 95 for 1996 to 1997. However, the percentage of recorded pregnancies ending in abortion (including spontaneous abortion) increased from an average of 14.3% between 1986 and 1990 to 16.8% between 1991 and 1995 and to 19.6% for 1996 and 1997. From 1986 to 1990, therapeutic abortions accounted for 35% of all abortions. The figure for 1991 to 1995, rose to 39% then fell to 21% in 1996 to 1997.
Figure 1. Abortions in Hermitte Ward 1987 to 1997
The abortion rate among pregnant women, excluding those who had a TOP, is shown in the last column of Table 1. From 1987 to 1995 abortion rates among pregnant women in Seychelles (excluding those having legal abortions but including other induced abortions and miscarriages) did not rise above 12.4% [The miscarriage rate among pregnant women is generally quoted as being between 10% and 15% (Berkow 1987)]. However, the 1996 figure was 15.6% and the 1997 figure 16.6%.
Over the 32 months from November 1993 to June 1996, at least 13 women whose request for a TOP was turned down were subsequently admitted to hospital with an abortion. At least 4 of these cases were septic (one required admission to ICU) and another 3 required a stay of 4 or more days in hospital. These 13 women represented 8% of women whose request for a therapeutic abortion was turned down. In addition, 2 women turned down for a TOP had threatened abortions. From July 1996 to December 1997, at least 15 women whose requests for TOP were not approved had an incomplete abortion (9 of them septic, including one with a possible perforation), representing 14% of women whose request for an abortion was not approved. In addition, another two women whose TOP request was turned down had threatened abortions.
In 1997, of the 9 women who had an abortion or threatened
abortion after their request for a TOP was turned down, 5 were beyond the
first trimester (12.5 to 14 weeks pregnant) when they made their requests.
Their abortions/threatened abortions took place 14 to 38 days after the
TOP requests were turned down. The other 4 requested an abortion during
the first trimester and aborted between 10 and 12 weeks.
Five women had 2 TOPs each during the whole 50-month study period. One of these had a re-sterilization followed by a repeat re-sterilization! Another had medical problems, which limited her contraceptive choices and put her at risk of serious complications during pregnancy. After the second TOP she was followed up by the gynecologists and required a third IUCD insertion because of complications with the first two. The third woman had an anencephalic fetus twice and the fourth was under 16 on both occasions. For the fifth one, there is not enough information in the registers to know why she required a second TOP. No one had more than 2 TOPs.
Many of those who had repeat abortions other than TOPs had planned and/or accepted the pregnancies and were having miscarriages. When post-abortion counseling by a primary health care nurse was introduced at the hospital in mid-1996, 42% of all women admitted because of an abortion were counseled. Among these women as a whole, at least 23% appeared to have planned the pregnancy but among those having repeat abortions there appeared to be a higher proportion of wanted pregnancies, indicating that women are more likely to have recurrent spontaneous abortions than recurrent induced abortions. In 1997, 7 women had 2 non-therapeutic abortions and 1 had a non-therapeutic abortion followed by a TOP.
| Table 2. Abortions & threatened abortions, 1994 – 1997 | ||||
| Year |
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|
|
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| 1994 |
|
|
|
|
| 1995 |
|
|
|
|
| 1996 |
|
|
|
|
| 1997 |
|
|
|
|
| Total |
|
|
|
|
Trends in annual numbers of threatened, therapeutic, septic and other abortions over the 4 years of the study are shown in Table 2 and Figure 2. The only remarkable change appears to be the increase in the number of ‘other’ abortions between 1995 and 1996. ‘Other’ abortions comprise spontaneous and illegal abortions, excluding those recorded as septic. There are no obvious reasons why there should have been a rise in spontaneous abortions in 1996. The rise in ‘other’ abortions coincides with the arrival of the antiprostaglandin, Cytotec, on the illegal abortion market. Access to this relatively effective, simple and private method of procuring an abortion may have resulted in more women with unwanted pregnancies successfully inducing an illegal abortion and then being admitted to hospital. It is possible that there were also a significant number of women who used this method and did not require hospital admission. This could be part of the reason for the fall in the fertility rate in 1997.
Figure 2. Abortions/threatened abortions, 1994 - 1997
Figure 3. Total abortions by age, 1994 -1997
Distribution of abortions by age
The distribution of abortions by age from 1994 to 1997 is shown in Figure 3. It is noticeable that women most at risk of dangerous abortions are women in their twenties, particularly those in their early twenties. This is also the age group with the highest birth rates in this country. Table 3 compares age specific fertility rates with age specific abortion rates for 1996. Although women in their early twenties have the highest age specific fertility and abortion rates, it is the older and younger women whose pregnancies are more likely to end in abortion. Table 4 shows that at current abortion rates, 1 in every 2 women will have an abortion in her lifetime.
Abortions among teenagers
Table 5 shows the number of recorded abortions among teenagers by single years of age in the 2-year period from January 1996 to December 1997. Almost half the teenagers having abortions were aged below 18. Under the age of 17, there were more therapeutic terminations of pregnancy than other kinds of abortion, while amongst girls of 17 and over, the reverse was true, especially among the 18 and 19-year-olds.
| Table 3. Age specific fertility rates (ASFR) and age- specific abortion rates (ASAR), 1996 | |||
|
|
|
|
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| 10-14 |
|
|
|
| 15-19 |
|
|
|
| 20-24 |
|
|
|
| 25-29 |
|
|
|
| 30-34 |
|
|
|
| 35-39 |
|
|
|
| 40-44 |
|
|
|
| 45-49 |
|
|
|
| Table 4. Age-specific abortion rates and total abortion rates, 1994 to 1997 | ||||
|
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| 10-14 |
|
|
|
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| 15-19 |
|
|
|
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| 20-24 |
|
|
|
|
| 25-29 |
|
|
|
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| 30-34 |
|
|
|
|
| 35-39 |
|
|
|
|
| 40-44 |
|
|
|
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| 45-49 |
|
|
|
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| Total |
|
|
|
|
| Table 5. Abortions among teenagers, 1996 – 1997 | ||||
| Age (yrs) |
|
|
|
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| 13 |
|
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|
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| 14 |
|
|
|
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| 15 |
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| 16 |
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| 17 |
|
|
|
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| 18 |
|
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|
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| 19 |
|
|
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| Total |
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|
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|
Table 6 shows that while most teenagers having a TOP were from Central or South Mahé, almost all the septic abortions and most ‘other’ abortions among teenagers took place in Central and East Mahé. This picture is similar for women having abortions as a whole except that there were relatively fewer TOPs among women from South Mahé as a whole compared to the situation among teenagers.
Distribution of abortions by region
Table 7 and Figure 4 show abortions by region for 1994, 1995, 1996 and 1997. The North is the only region where the overall number of abortions has decreased from 1994 to 1997. The East, with increasing numbers of septic and "other" abortions, showed the largest increase of all the regions, equaling Central for the highest number of abortions in 1997.
Distribution of abortions by employment/economic status
It is not possible to make any conclusive remarks about employment/economic status because employment was not specified in a large proportion of cases. Both employed and unemployed women had abortions. The proportions in the different income brackets for all abortions together seem to roughly reflect the proportions of women in these brackets in the country as a whole. Student teenagers are more likely to have a TOP than a non-therapeutic abortion while unemployed teenagers are more likely to have a non-therapeutic abortion.
| Table 6. Abortions among teenagers by region, 1996 - 97 | ||||
|
|
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| Central |
|
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| East |
|
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| North |
|
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| South |
|
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|
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| West |
|
|
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| Praslin/LD |
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| Total |
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| Table 7. Abortions and threatened abortions by region, 1994-97 | ||||||||
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| Threatened | ||||||||
| 1994 |
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| 1995 |
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| 1996 |
|
|
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|
|
|
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| 1997 |
|
|
|
|
|
|
|
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| TOP | ||||||||
| 1994 |
|
|
|
|
|
|
|
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| 1995 |
|
|
|
|
|
|
|
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| 1996 |
|
|
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|
|
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| 1997 |
|
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|
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|
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| Septic | ||||||||
| 1994 |
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| 1995 |
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| 1996 |
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| 1997 |
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| Other | ||||||||
| 1994 |
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| 1995 |
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| 1996 |
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| 1997 |
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| Total* | ||||||||
| 1994 |
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| 1995 |
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|
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| 1996 |
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| 1997 |
|
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| * Does not include threatened abortions | ||||||||
Contraceptive use before and after abortion
Limited information is available on this. The only information available from the ward register and forms concerns those women sterilized at the time of having a TOP and at least some of those who were using an IUCD. There was no additional information about contraception in the TOP register. The other information is from the register of clients who receive contraception (mostly IUCDs) from the gynecology outpatient clinic (started in May 1996) and from the post-abortion counseling register. From July 1996 to December 1997, 42% of all the patients admitted to hospital because of an abortion received post-abortion counseling at the hospital from a primary health care nurse who kept a register of all the patients she saw. The intention was to counsel all women who were admitted to hospital because of an abortion but because of the staffing situation, more than half the women were discharged from hospital before the nurse had time to see them.
Figure 4. Abortions by region, 1994-1997
Of the 355 women who had a TOP over the 50 month study period, 89 (25%) were sterilized at the time of the abortion or soon after. At least 9 of the 1424 women who had any kind of abortion during the study period were pregnant with an IUCD in situ and 4 had been sterilized. Among the 575 women who had an abortion between July 1996 and December 1997, there were 263 (46%) for whom the records studied indicated that their pregnancy was unplanned. Some information on contraceptive use/non-use was available for 167(63%) of these women: of the 47 teenagers, 24 (51%) had never used contraception, while out of the 88 women in their twenties only 4 (5%), all in their early twenties, had never used contraception. All 32 women aged 30 or over had used contraception at some time.
Among the 263 women with unplanned pregnancies referred to above, information on contraceptive use at the time of conception was available for 136 (52%) of them (see Table 8). The records studied specified that a contraceptive method was being used by a further 23 women around the time of conception but although the method was recorded the records did not specify whether pregnancy occurred as a result of method failure or user failure.
| Table 8. Contraceptive history at conception of some of the women with unplanned pregnancies resulting in abortion between July 1996 and December 1997 | ||||
|
|
|
|
|
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| <20 |
|
|
|
|
| 20-24 |
|
|
|
|
| 25-29 |
|
|
|
|
| >30 |
|
|
|
|
| Total |
|
|
|
|
Of the 57 women who had an abortion between July 1996 and December 1997 for whom the contraceptive method in use around the time of conception was specified, 22 were taking the pill, 21 were using condoms (3 with periodic abstinence or withdrawal), 8 were using periodic abstinence, 5 had an IUCD and 3 were using withdrawal.
Of the 575 women who had an abortion between July 1996 and December 1997, 88 (15%) left the hospital with a method of contraception, including 23 who had a sterilization with a TOP. A further 68 (12%) received contraceptive counseling at the hospital but they decided they would rather go to their FP clinic to get their chosen method. In most cases they planned to do this within a month of being discharged from hospital. Another 8 women who were counseled (7 of them teenagers) chose sexual abstinence and at least another 8 teenagers went home without any definite plans even after counseling.
For the remainder of those counseled at the hospital and for the 58% who were not counseled, information about post-abortion contraceptive use/plans was not available in the records studied. Among those who received post-abortion counseling at the hospital, about 30% took a contraceptive, about 30% decided what method they would get from their FP clinic and about 40% apparently went home undecided.
Proportions of pregnancies ending in abortion that were recorded as induced, unplanned or planned
Table 9 shows what proportions of the 575 pregnancies ending in abortion from July 1996 to December 1997 were recorded as induced, unplanned or planned. Some information was available for over three quarters of the teenage pregnancies but for less than half of the pregnancies in older women. This may be partly because teenagers were more likely to obtain legal abortions. They may also have been more likely to receive post-abortion counseling at the hospital since they belong to an easily identifiable high-risk group. It would appear that teenagers are also more likely to admit to having induced an abortion illegally. Although none of the teenage pregnancies were recorded as having been planned, 5% of the girls said they had accepted their pregnancies and so presumably their abortions were spontaneous. There were another 18% who said their pregnancies were unplanned but the records did not indicate whether these pregnancies were accepted or whether any attempt was made to obtain an abortion. Among the older women, 10% of the pregnancies were recorded as having been planned and another 5% had been accepted.
| Table 9. Percentage of pregnancies ending in abortion from July 1996 to December 1997 that were recorded as induced, unplanned or planned | |||
|
|
|
|
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| Legal, induced |
|
|
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| Other, induced |
|
|
|
| Unplanned, accepted |
|
|
|
| Unplanned, not known if accepted |
|
|
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| Planned |
|
|
|
| Not known if planned |
|
|
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| Total |
|
|
|
If all the women for whom information was available, concerning whether or not their abortion was induced, are representative of the women having abortions as a whole, then 32% of all the abortions were spontaneous and 74% of the non-therapeutic abortions were spontaneous. However, as stated previously, the impression obtained by the author from the medical notes of women who had abortions during the first 32 months of the study, was that the proportion of non-therapeutic abortions that were spontaneous was closer to one third than three quarters. This could have changed by 1997 (the last 12 months of the study) but it is reasonable to presume that women are more likely to say when their pregnancies are wanted/accepted than they are to say when they have induced an abortion.
History of previous pregnancies among women having abortions
Table 10 shows the number of women who had abortions in1997 by parity, order and type of abortion. In 45% of cases, the parity was not specified. However, among those where the parity was recorded, the majority of abortions were among women of low parity. This applied to all types of abortions but there were relatively more women with more than one child among those who had a TOP. The proportion of women of parity 4 or more was 3 times as high among those who had TOPs compared to the others. This may be because a woman of higher parity is more likely to face a medical problem for which therapeutic abortion is required.
Presumably multiple abortions are more common among the ‘other abortion’ group at least partly because the figures include women who are trying for a pregnancy and are having recurrent miscarriages caused by medical problems such as cervical incompetence.
| Table 10. Number of women who had abortions in 1997 by parity, order & type of abortion | ||||
|
|
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|
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| Para 0 |
|
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| Para 1 |
|
|
|
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| Para 2 |
|
|
|
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| Para 3 |
|
|
|
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| Para 4+ |
|
|
|
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| Not specified |
|
|
|
|
| Total |
|
|
|
|
| 1st abortion |
|
|
|
|
| 2nd abortion |
|
|
|
|
| 3rd abortion |
|
|
|
|
| 4th abortion |
|
|
|
|
| Not specified |
|
|
|
|
| Total |
|
|
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|
Table 11 shows that most parous women who had an abortion in 1997 had had their last delivery 2 to 5 years before the abortion. None of the women for whom the information was available in the records studied had a child under one year old and only 8 (13%) had a child aged under two years old. Postnatal registers in the FP clinics show that almost all women who have a sexual partner start using contraception 6 weeks after delivery. Some of the women in the study probably became pregnant when they stopped using their contraceptive method because of side effects, because they became ‘tired’ of using contraception and/or because they became careless in the use of their method. Others may have stopped using contraception when a relationship ended and not started again before renewing sexual activity. It is probable that some of these unwanted pregnancies could have been avoided if the women had received better counseling and follow up than they did.
The last delivery for the women having a TOP tended to be more recent than for the other women. This may be partly because the former had medical conditions that limited their contraceptive options (thus making it more difficult for them to avoid pregnancy), as well as being grounds for therapeutic abortion. The gap since the last delivery tended to be longer for the women having ‘other abortions’, probably because some of them had waited until they were ready for another child and then when they tried to have another baby, they experienced one or more miscarriages.
| Table 11. Time since last delivery among parous women who had an abortion in 1997, for whom parity was recorded | ||||
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|
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| <2 yrs |
|
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| 2-3 yrs |
|
|
|
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| 4-5 yrs |
|
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| >5 yrs |
|
|
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| Total |
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|
Discussion
While the number of pregnancies recorded per 1000 women aged 15-49 per year has been falling, the proportion of those pregnancies ending in abortion (including spontaneous abortion) has been rising: from 14.3% in the late eighties to 19.6% in the mid-nineties.
In Seychelles, probably between 1.5% and 2.0% of women aged 15 to 44 have an abortion each year and probably fewer than one in five pregnancies are deliberately terminated. Although these figures indicate that Seychelles may still be among the countries that have the lowest induced abortion rates in the world, an increasing proportion of abortions over the past four years have been non-therapeutic (spontaneous or illegally induced), with a particularly noticeable increase in 1996.
This may be partly because, as women become more successful at avoiding unplanned pregnancy, abortions happening spontaneously to women who have planned their pregnancy account for an increasing proportion of all abortions. Another contributing factor could be the fact that many of the women who are least effective at avoiding unplanned pregnancy are also those who are least able to accept the pregnancy or to seek/obtain a legal abortion, and are therefore more likely to have an illegally induced abortion. During the study period, the proportion of women whose request for a therapeutic abortion was rejected who ended up having an unsafe abortion, rose from 1 in 12 to 1 in 7.
Almost half the teenagers who had an abortion in 1996/1997 were under 18. Out-of-school unemployed teenagers seem to be particularly at risk of non-therapeutic abortions. Among girls under 18, 44% of the abortions were non-therapeutic while the figure for young women aged 18 and 19 was 76%. Non-therapeutic abortions are more common among women in their twenties than among women in any other age group. However, because they also have a higher pregnancy rate than any other age group, the proportion of pregnancies that end in abortion is lowest in this age group.
Most women having an abortion in 1997 had less than 2 children. However, higher parity pregnancies were more common among women having a TOP, probably because these women are likely to be older and to have more medical grounds for therapeutic abortion. Medical risks also increase with increased parity.
The information available for 1997 indicates that about 15% of the women admitted to hospital because of an abortion had had at least one previous abortion (usually non-therapeutic). It seems that a significant proportion of these repeat abortions were spontaneous.
From July 1996 to December 1997, Central and East Mahé had the highest number of teenage abortions and North Mahé the lowest. This is partly because the former two regions have larger populations but they also have large housing estates which are home to some of the more socio-economically disadvantaged members of society. Among the remaining regions, North Mahé is the most urban. While North Mahé is the only region where the number of abortions has decreased since 1994, the East now has as many abortions as Central Mahé (the largest region in the country). The increase in the East has been in non-therapeutic abortions.
From July 1996 to December 1997, among the women aged 20 or over with unplanned pregnancies, it appears that almost all of them had used contraception in the past although around 70% were not using a method at the time of conception. However, among the teenagers, about half had apparently never used contraception. This confirms that the needs of teenagers, and the services required to meet those needs, are different from those of older women.
Recommendations
File numbers, dates of birth, FP clinic and diagnosis (not symptoms or procedures) should be recorded in the ward admissions register.
Quality contraceptive counseling and effective arrangements for follow up should be an indispensable part of the routine care given to women by both hospital staff and primary health care providers. Both the contraceptive history and information concerning counseling provided and recommendations should be recorded in the gynecology and maternity notes.
A way should be found of ensuring that patients files are kept in order, with all the records of related medical management in one file, so that there is better continuity of care, important information is easily retrieved, different people’s notes are not mixed up and time spent with the patient is used more effectively.
The format/content of the TOP register should be reviewed.
Primary health care workers, especially those in East and Central Mahé, should focus on young unemployed women aged 17 to 24 and work with them and their families to find ways of helping them avoid unwanted pregnancies and unsafe abortions.
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